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1lE DEVELOPMENT OF RURAL DISTRICT NlRING

IN GLOUCESIERSIIIE 1111)-1925

A thesis submitted to The University of Gloucestershire

in accordance with the requirements of the degree of Doctor of Philosophy in the Faculty of Humanities

(2)

IMAGING SERVICES NORTH

Boston Spa, Wetherby

West Yorkshire, lS23 7BQ www.bl.uk

CONTAINS

PULLOUTS

(3)

ABSTRACT

This Thesis examines the development of trained district nursing in rural Gloucestershire from the 188Os, when Elizabeth Malleson, founder of the Rural Nursing Association (RNA), moved to the area, until 1925, when the first State Registration examinations were held and a new era began for the entire nursing profession. The transition from local provision of aid by untrained women to the organised delivery of care by specially trained nurses employed by the RNA is

described, and the expansion of this local charity into a national scheme is traced to its affiliation and eventual amalgamation with Queen Victoria's Jubilee Institute for Nurses (QVJI), the organisation from which the current system of district nursing has evolved.

The aims and motivation of the midde-and upper-class ladies who became involved in the administration of the rural district nursing movement are considered, with particular reference to religion, politics and the opportunity to expand their lives beyond the limited role prescribed for them by the cult of domesticity. The official aims of the district nurses themselves, of curative care and preventative education, are traced, and theory and practice are then compared and contrasted. The working lives of the district nurses are described, including their duties, workload, salaries and living conditions, with additional reference to the contemporary ideologies of 'fit work for women', social isolation versus independence, and relationships with administrators and local doctors.

Consideration is also given to the question of whether the service provided by those who believed that they knew what the sick poor needed was, in fact, what the poor themselves actually wanted. To this end, the educative aims of aVJI are

examined in comparison with two of the most fundamental and sustaining elements of life amongst the

poor,

especially in isolated rural communities - neighbourliness and

(4)

AUTHOR'S DECLARATION

I declare that the work in this thesis was carried out in accordance with the regulations of the University of Gloucestershire and is original except where indicated by specific reference in the text. No part of the thesis has been presented to any other education institution in the United Kingdom or overseas.

Any views expressed in the thesis are those of the author and in no way represent those of the University.

(5)

ACKNO~DGEMENTS

It would not have been possible to complete this PhD Thesis

without

the kind and generous funding from the Macfarlane Walker Trust. Thanks for advice and help are due to: the staff at the Gioucestershire Record Office and Cheltenham Reference Ubrary; Dr Anne Summers of the British Ubrary; Helen Wakely of the Contemporary Medical Archives Centre; Maggie Wheel of Inter-library Loans at the University of Gloucestershire; Mary Southerton, Jane Sale and Mary Paget of the Charlton Kings Local History Society; Lord St Aldwyn, for access to the private family papers of Lady Lucy Hicks-Beach, and Maggie James of the Williamstrip Park Estate Office who located and photocopied the papers.

Special thanks are due to my friend Hazel Parris, who copied records from the Queen's Roll for me; and to my SUpervisors, Dr Melanie llic of the University of Gloucestershire, and Professor Diana Woodward of Napier University, Edinburgh, for their advice, help, encouragement and support.

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CONTENTS

Diagram: Chronology of development of rural district nursing

Diagram: Organisational structure of QVJI ii

Abbreviations iii

INTRODUCTION 2

CHAPTER ONE HEALTH CARE IN THE 1880s

Institutional care 21

Patent and Folk Medicines 33

Lady Bountiful 40

CHAPTERlWO CHRONOLOGY OF DEVELOPMENT OF

RURAL DISTRICT NURSING

Elizabeth Malleson's early life and work 51

The Village Nursing Association 58

Queen Victoria's Jubilee Institute for Nurses 65

The Rural Nursing Association 70

Affiliation and Amalgamation 81

CHAPTER THREE AIMS AND MOTIVATION

Lady Administrators 90

The Nurses 103

CHAPTER FOUR PROFESSIONAL AND SOCIAL STATUS

Relationships with Doctors and Committees 122 Social Backgl'OU'ld and Training of Queen's Nurses 131

Training of VNMs 141

CHAPTER FIVE CHAPTER SIX

THE WORKING UVES OF THE DISTRICT NURSES 158 THE UVING STANDARDS OF THE

DISTRICT NURSES Salaries

Accommodation

183

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CHAPTER SEVEN THE PATIENTS' VIEWPOINT CONCLUSION

APPENDICES

1 Examination paper for the Roll of Queen's Nurses. 1924 2 Extracts from Central Midwives Board First Rule Book, 1903

3 Records of Queen's Nurses who worked in Gloucestershire 4 Minimum Requisites for a Nurse's Cottage, c1910

BIBUOGRAPHY Illustrations 218 246 257 258 260 287 288

The Queen's Nurse 1924 1

Gotherington in the late 19th century 20

Elizabeth Malleson c.1890 49

Queen's Nurse Ann Newdick 1935 89

Gloucestershire District Nurses at Cheltenham Town HaJ11925 121

Queen's Nurse Jemy Wolfe at Gotherington c.1895 157

County Superintendent Lena Milford c.1940 182

Apple pickers in rural Gloucestershire c.1912 217

HRH the Duchess of York and the Dowager Duchess of Beaufort during 245 the royal visit to Cheltenham 1925

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Chronology of development of rural district nursing ~ 1860s 1875

1884

1889

1890 189112 1897

Elizabeth Malleson founds local Village Nursing

Association in Gotherington, Gloucestershire

Elizabeth Malleson founds national Rural Nursing Association

William Rathbone sets up district nursing scheme in Uverpool William Rathbone and Rorence Nightingale form The Metropolitan Nursing Association in London

Queen Victoria's Jubilee Institute for Nurses established

RNA affiliated to aVJI as its Rural District Branch

(9)

Organisational structure of QVJI

Queen's Council - employed ---...,. Inspectors

(appointed by the monarch) (Queen's Nurses & Midwives

1

who toured

1'18

country)

County Nursing Associations - " (representatives of DNAs)

1

District Nursing Associations - " (each run by lady Administrator

& local Committee)

-~~ County Superintendents (Queen's Nurses & Midwives

who supervised nurses)

1

-~) Queen's Nurses & Village Nurse-Midwives

(10)

Abbreviations

BMA British Medical Association

CMB Central Midwives' Board

CNA County Nursing Association DNA District Nursing Association

GMC General Medical Council

IWC Infant Welfare Centre

LOS London Obstetrical Society

MNA Metropolitan Nursing Association MOH Medical Officer of Health

QN Queen's Nurse

QVJI Queen Victoria's Jubilee Institute for Nurses RNA Rural Nursing Association

VNA Village Nursing Association

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GOVERNMENT & HOSPITAL

CONTRACTORS

Fon ALL KIN[)S OF

N

URSES' UNIFORMS

COATS, CLOAKS, BATS, BONNETS,

llltESSES, OVEHAlI,S, CArs, Al'IlONS, COLLARS, CUFFS, Etc.; 1\1.0 SlIHGlCAL INSTltllillENTS

1\!1<1 Al'l'LIANCES,

!'T' lllltslrtltri/ Catalogue PelsJ Fru.

·".,THE "FLORA" APRON

(\VITI' CORm S<,"1).

r,{Anr" Iff OUR \\"OItK H.()OMS OP' LI~'Hi·TINISIIEU ( I UTil, Srl~rlAI.IX MANUFACrUIl1!.l) FOR t~AR' RfHILP'S. (PATTJ~n="s POST l;ur:I-.)

l.E~H~ll1 OP SKIltT ; - ) J , 3f •. \6, 3M ills.

\VlIJ111 OF SI\.1Rr :-bn ins.

\V"I<iT HAl'll) TO F"-rt:N : - l q to 30 ins. I'R,ns' -2/11. 3/11, 4/11 "",15/6 ,"ell.

AI SO III UtnON AT 6/11 (,Oleh.

ALSO IN OUTSI7J~ :-\VII>Ttl fll' SKII\T, 7$ ill"_

,l\tFI~TS AT BACK, \VAJSr H'~ln, 33 ins. 41ft

amI 6/1 teach,

~ CMmOULO·S I lAVE BEEN OFFICIALLY

l APPOINTED llY 'II IE CENEHAL NUHSINC

l COUNCIL TO SUPPLY lHE

l

STATE REGISTEnEO UNIFORMS

l ... Pric .. , Palltrn., and

SelE-Me.lUre-1 ment Fonn. Po It Free.

CAHI!nULO·S SUPPLY 111E

COMl'a-:-IE UNIFORM OF

THE QUEEN'S NURSES ALSO n IE QUEEN'S [JAG. 1, ... PricCl, Particu1nn nnd Self ..

MeDal1r~lntnt Funns POlt Free GARr~l~lU~~;:,~r~~~~:EUr.l'> ~.ilr 1, x 161 x ,I int'lu's.

(A, illustration.)

III Plllvi~ulII. uufiltr.41 82 '0 In PluviC'lllo, fllle''' .. 58 '0

In Cowhide L-.;atih'l, ul1fitlNI 50/0

In Cowhidl! Leather, fittrll 78 r. P;H !kulu" rof hHillG Post Free'.

E . .t!r:. R . G - A T I n O U L D ,

HiO to 162 Edgw~re Road, London, W.2 1 c1,.,rann-" Gnrrnul,l, Fd2e. Lonclm." T,/,p}'''''tJ-5320. 5321 & 62971'.d~.

--... --r----. - - _ ... - .. -'-. ---~---The QUee11' s Nurse, 19'24

W. H. BAILEY

&

SON

THE LATEST INVENTION

f

. "

"Per echon

ri

--

-~

0'""'

~_

Irr::l::rr~

Midwifery J.

~hl;;'

~'{

:

iM

Case (Rellistered). BLACK OR BROWN Si, •. 16 X 61 X 10

ins. deep, witla rc-movllhlc: lininfl'.

/)

Cue EIIlPl}'. ill I1exine 37/6 Empty. in Cm..Jlillc 56 6 C05e Fitted Complt."le in Hexille. 6-1.' FIIIt.:d C0l1111lcte. in Cn .... hidc: 83/

POCKET URINE TEST CASE.

TillS small compact set has 1~l:n

ocsis:ned for Midwives praclisin\{ in rural dislricls. Contents:

-2 Stoppered DOilies for

Rc-aKenlS, 2 Nested Test Tubt,s,

511l .. 11 Oran Spirit Lamp. In null.o{( ~xine Case, 7/6 neh.

Post 4J. extra. Surgical lnstrunlcnts and

THE QUEEN'S BAO. Blade O( nrowil COWIIIDE. wilh e~t ... outsiJe

pOlkct, removable washahle Ilnin~. Very

("00-vell~nl fur a cycle.

nClQ' onlt 32 6. Filice! complete 61/9.

Spare L.illilljl 5/6.

Appliances. Hospital and Invulid furniture.

45 OXFORD STREET,) LON DON W 1

2 RATHBONE PLACE,f ' •

Suurce: Some Queen's Superintendents, 'Handbook for Queen's Nurses'

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INTRODUCTION

This study examines the development of trained district nursing in rural

Gloucestershire from the 1880s to 1925. This period begins when Elizabeth Malleson, founder of the Rural Nursing Association (RNA), moved to the area from London, and ends when the first State Registration examinations were held and a new era began for

the entire nursing profession. I first became interested in this subject when I completed an MA in Cultural, Uterary & Historical Studies, the theme of which was the change from a predominantly rural to an urban society from 1750 to 1950. For my Dissertation,

I chose to study improvements in rural health care in the late nineteenth century,

which, as a former nurse, reflected my interest in the history of nursing in general.

During my initial MA research, I came across a brief reference to Elizabeth Malleson and the RNA, which I thought at first would prove to be only a small local charity. However, when I visited the Gioucestershire Record Office (GRO), to see if they held any relevant primary source documents, I

folJ'ld

that the RNA not only grew into a national charity, but also eventually became an integral and very important part of Queen Victoria's Jubilee Institute for Nurses (QVJI)*, the organisation from which today's system of district nursing has evolved. It

was

beyond the scope of an MA Dissertation to make full use of all the available primary source material, so I concentrated only on how Elizabeth Malleson first set up her charity, then applied to continue and expand my research as a PhD Thesis.

It quickly became obvious that related secondary sources, whilst including district nursing in their study of philanthropy and nursing, saw it only as

a

footnote

to

the broader context of social history, instead of recognising it

as

central to pre-NHS welfare policies. As nursing historian Maggs states, the predominant historical role of district nursing 'ies in its value in aiding our l.Ilderstanding of class and social

relationstips .... In partia.W, we need to know much more

about

how the patient and *1he title of QVJI

was

changed in 1928 to the Queen's Institute of District Nursing

and later still to the Queen's Nursing Institute. Throughout this study, which covers

the years 1881-1925, the

or9laI

title is used, tI10lql some quotes from secondary

(13)

the relatives reacted to the introduction of 'trained' nursing into the family and

household setting." (1) Dingwall et

aI

agree and offer an explanation for the dearth of in-depth studies devoted exclusively to this particular branch of nursing: "District nursing ... has been relatively neglected .... Its past is not preserved in major official archives but in the scattered records of local voluntary associations which, if they have survived at all, are less readily located and more laborious to collate." (2)

Despite this acknowledgement of district nursing as a neglected area and the call twenty years ago for further research, only Fox has completed a recent study, whilst Helen Sweet is currently undertaking research at Oxford Brookes University. Fox describes her unpublished PhD thesis as "a case-study in voluntarism". She stresses that "the obscure but complex history of ... rural district nursing must be brought into a prominence that may seem unreasonable for twentieth century Britain, a largely urban society", but she acknowledges that her own study, "makes no

systematic use of oral history and barely disturbs the locally surviving records of DNAs [District Nursing Associations]. Its main sources are the partial, but centrally held records of the Queen's Institute and those of the Ministry of Health." (3)

Thus, Fox concentrates on central policy-making, as do the

two

slim volumes by Stocks, A Hundred Years of District Nursing (1960), and BaIy, A History of the Queen's Nursing Institute (1987). These two books remain the main sources on the history of aVJI, the central body which standardised training and unified existing philanthropic schemes through its system of inspection and affiliation. Dingwall et

aI

describe these studies as "useful books" (4), but the scope of both is limited by the fact that they were commissioned to celebrate milestones in the history of district nursing. They are, therefore, designed to be congratulatory and to emphasise positive progress over the years. "From Buckingham Palace through the drawing-rooms of Mayfair and Belgravia

and

the mansions of the country aristocracy, a line of causation carried the energies of the new organization

out

to the front line of the war against disorder and disease," Stocks enthuses. (5) BaIy adds, "The Queen's nurses, fOlIlded as a Victorian charity, ... spearheaded a universal community nursing service of high

(14)

quality, ... a testimony to ... the esteem in which the Queen's nurses were held." (6) Baly uses Stocks as her main secondary source and both books are factual and informative rather than discussive and analytical. They concentrate on the leading figures of the movement, not on the nurses themselves, and

on

details of politics and organisation, not on the day-to-day duties and problems involved in nursing the sick

poor in their own homes.

Maggs considers this approach to be typical of historians and to have led to an "imbalance within the historiography of nursing". (7) It is the approach taken by AbeI-Smith, whose book, A History of the Nursing Profession (1960), has become a classic text on which subsequent historians still rely heavily after forty years. As Davies says, "It is easy to see it, not as a history, but as the history of nursing." (8) AbeI-5mith makes it clear from the outset that

this is a study of the 'politics' of general nursing from 1800 onwards. It concentrates on the structure of the profession, on recruitment, on terms and conditions of service .... No attempt is made to provide a history of nursing techniques or of nursing as an activity or skill. UttIe is said about what it was like

at

different times to nurse, or be trained as a nurse, or to receive nursing care.

He concentrates on "general nursing in the hospital setting", not because "other fields of nursing practice, outside as well as inside the hospital, are any less important", but

"because this is where nurse training has been conducted". (9)

Maggs designed his own study, The Origins of General Nursing (1983), to complement AbeI-5mith's work by concentrating "on the experiences of the nurses themselves rather than the leadership or reformers of the profession". (10) He identifies four core features of probationers: the age

at

which women began nursing, their previous work experience, educational background and social origins, but he, too, concentrates on general, i.e. hospital, nursing. However, although Maggs attempts to address the questions which AbeI-5mith leaves unanswered, he, too, by focusing on "the way in which women chose and were chosen to be general nurses" without then progressing to "describe 'ministering angels'

at

work in the world" (11), presents an incomplete picture.

(15)

recruitment, result in what Newby describes as not so much a history of nursing but "a history of nurses in old fashioned chronological catalogue form, consisting of dates, acts, institutions, committee personalities, recruitment numbers and duties (the latter, if lucky, in primary source quotation though often bordering

on

a 'linen list')". (12) If

'history of nursing' is not

to

be a misnomer, it must be viewed in its social context, not in isolation, for as Mortimer says, "of all occupations, nursing is one which is deeply

involved in and dependent on local society and culture to define and provide the work which is to be done". (13) Conversely, an historical knowledge of nursing is needed to

provide

an

understanding of the nurses' contribution to that society at all levels of class and of their achievements within a developing profession. It is the aim of this study to examine the change from traditional benevolence

to

the provision of professional nursing

care

in rural Gioucestershire through the lives of and relationships between three tiers of local society: the middle-and upper-class ladies who devoted years of their lives to the administration and management of the rural district nursing system, entirely on a voluntary basis; the specially trained nurses who delivered the care; and

the poor patients who benefitted from it.

To achieve this wide-ranging yet integrated picture of three distinct social groups, it proved necessary to rely heavily on previously unused primary source material, particularly the records of the nurses' working lives. Whilst philanthropy has been relatively widely researched, available secondary sources tend to discuss the aims and motivation of altruistic women in very general, traditional terms, whereas district nursing offered new and wider opportunities both to the lady administrators and the nurses themselves.

A

resume and critique of the views of other historians, who tend to quote extensively from one another on this topic, is useful here

to

illustrate their approach, before the primary sources are discussed with reference to the specific themes of this Thesis.

McKibbin sees Victorian philanthropic work as an agency for improving social

conditions

and changing working-class attitudes, based 00 the belief

that "they

had been taught foolish habits and, since that was so, they could be untaught them" (14).

(16)

Stedman Jones, however, views charity as a means of social control by maintaining class differences between the rich and poor. He describes the traditional social meaning of charity as a "symbol of prestige" and "as a method of social control": to give, denotes superiority; to accept, implies subordination and subservience, for "in order to receive one must behave in an acceptable manner, if only by expressing gratitude and humility". Late nineteenth century campaigns sought to harness overlapping, individual charities and co-ordinate philanthropic activities, whilst establishing the Poor law "as a penalty for moral and economic failure". Thus, the clever pauper, who took advantage of such indiscriminate aid "by moving swiftly and skilfully from one charity

to

another", would be forced "to tum back from mendicancy to labour" whilst the honest poor "would be led back to manliness and independence under the firm but benevolent aegis of a new urban squirearchy". (15)

However, there is one vitally important element of Victorian philanthropy which neither Jones nor McKibbin mention: genuine compassion. As Prochaska expresses it, "Cynics might argue that the poor are with us so that the rich may be virtuous ... [but] charity could

not

pauperize a starving child and the dead are rarely hypocrites." (16)

Summers adds that "it is belittling and insulting to suggest that women had only a negative motivation for their actions ... and it is historically unheIpfU to suggest that thousands of incividuals acted without positive motivation or the exercise of choice". (17)

For many women in the late nineteenth century, be they leisured ladies who offered their services as volunteers for charities, or working women who chose to train for a career in nursing, providing and caring for the poor and sick was

not,

in

Prochaska's words, "simply a Christian duty, though that was a good part of it; it represented basic human urges: to be useful, to be recognised, to be informed". (18) Summers describes such work as "an engagement of the self which involved the sacrifice of leisure and the development of expertise". (19) Prochaska adds that "to be needed, to be COtJ"lted upon ... by those more obviously in distress was a

great

reward ... [and] such experiences made up for the rebukes, the heartaches, and the doors

(17)

slammed in the face". (20)

Holcombe points out that "no aspect of the women's movement is more striking or important than the transformation of nursing from a refuge for the outcast into an honourable and skilled calling, and a very popular one as well". (21) In the case of district nursing in particular, "a special class of nurses" (22) was needed, each of whom, in the words of Dingwall et ai, "must rely

on

her personal qualities and skills" (23), for as Summers says, "not every well-meaning woman was capable of

entering the wretched tenement or hovel of a total stranger". (24) Prochaska agrees that

it

could

be a harrowing experience to enter the homes, often hovels, that

so

commonly made up a district. ... The poverty was

so

profound, the disease and hardship

so

overwhelming, that abstract debates about the value of charity were often out of place .... When confronted with death

and dying, they acted in the only way they knew, with compassion. (25)

Holcombe concludes that, in district nursing, "perhaps more than in any other branch of the profession, educated women fOlJ'ld wide opporbrities to lead independent,

interesting and useful lives". (26) However, whilst historians such as Summers and Prochaska emphasise, in the words of the latter, that women involved in philanthropic work "had every reason to be proud of the countless mercies shown to the victims of accidents and infectious diseases, to the lonely, to the aged, to pIl9l8nt women, to starving children" (27), and Holcombe highlights the value and importance of district nursing, they all tend to

concentrate

on

urban areas, particularly London. Sttdes of rural commlJ'1ities in the late nineteenth century are scarcer, particUariy those wtich emphasise the philanthropic role of women.

Mingay covers Victoria's entire reign, but confines himself

to

a detailed discussion of the lives and roles of "the politically powerful but often paternal landlord, the oId-fastioned gentleman farmer who respected the land which he tilled and the men he employed, and the old-style labourer, ponderously

icJlorant

and conservative, but

steeped in his COU'ltry skills". (28) When discussing landowners, Mingay states that, "polite and kind, as he often

was,

the sqtjre usually tI1otq1t it below his dignity to go into the villagers' homes and try

to

get

to

know them individually" (29), but he does

(18)

concede that "wives visited the sick, dispensed old-fashioned remedies in their kitchens, prepared soup for the poor, and distributed coal and blankets to needy families at Christmas". (30) His only other reference to women's involvement in philanthropic work is in his chapter on 'Professional People' where the two paragraphs that he devotes to doctors include the passing comment that "after mid-century ... the doctors' work was complemented by the services of District Nurses". (31)

Mingay concludes that "the extent and complexity of the social problems of the countryside ... [resulted in] a growing distance, a greater hostility between the wealthy and the poor". (32) However, as Gerard points

out

in her well-expressed and

considered article, "in confining their analysis to men's activities, achievements, and accounts, historians overlook the vital contribution of landowners' wives, daughters, and sisters, and consequenUy seriously underestimate the actual level of interaction between the landowning family and local people". (33)

The study by Hom could be classified as a companion volume to Mingay. In her readable and entertaining style,

Horn

details every aspect of the lives of ladies in landed society, including four pages on their involvement in district nursing schemes, using Stocks and BaIy as her main sources. However, Hom's approach is narrative rather than interpretative. Although she briefly defines the cult of domesticity as "the 'natural' separation of the male and female spheres in life, and the importance of hearth and home as the centre of female existence" (34), she does

not

analyse the political, religious and social factors which formed the ideological foundations of this cultural philosophy. Nor does she discuss the historical relevance of women's "role as dispensers of charity and other aid" (35) beyond saying that they acted "as a 'golden

bridge' between the elite families who wielded power in the Victorian COU'ltryside and the cottagers who were their subordinates". (36)

In rural communities, as Gerard points

out,

"the lady of the manor's duty of personally attencing the poor and sick had been established since the Middle Ages". (37) One vital factor in this Iong-accepted social relationship was "the

(19)

help, advice, influence and gifts .... The Lady Bountiful came to know the life history of every person in a small, fairly stable community. Thus she could readily identify the deserving and underserving." (38) Gerard believes that, "though they joined with middle-class women in many philanthropic activities when in london, women of the landed classes were still a distinct group, with different motives and spheres of interest. ... They knew the poor better and often developed a warmer relationship with them than did middle-class lady visitors in the slums." (39) It was their social position that gave such ladies the power, resources and influence to ameliorate the problems caused by that very class gulf and in philanthropy they found "a socially approved outlet for their talents and needs .... They gained a

sense

of usefUness and worth." (40)

Only in one paragraph does Gerard mention that "women of the landed classes ... became prominent in forming branches of the District Nursing

Association"

(41), but she does

not

consider the significance of this change in philanthropic approach. In any historical period, there were always women of the social and political elite who quietly and unobtrusively used their influence for the benefit of philanthropic causes and good

works, yet who, as Williams says, "made no mark at all on national life" (42), whilst, at significant moments, others emerged who "were driven by a campaigning zeal that transformed public opinion in Britain on important and controversial issues". (43) Nursing produced a number of such dominant and outstancing women amongst its leaders and reformers, particUarty in the period from 1860 to 1920, characters who Bowman describes as

veritable giants of personality and achievement. Such individuals

are

never easy to deal with, ... yet it is people of this dominating, overbearing nature who

are

necessary to the founcIng of almost any new enterprise -and who have appeared

so

often just when they were needed. (44)

In the field of rural district nursing, Elizabeth Malleson was one such

campaigner. Her biography, a copy of which only came

to

light after Stocks had

written her history of aVJI, is an invaluable primary source,

not

only of details about the formation of the RNA, but also about the profould and far-reaching effects that one

(20)

necessary to bear in mind the purpose and audience for which the biography was produced and the possible bias and selection of evidence by the author. It was written in 1926, ten years after Elizabeth Malleson's death, by her youngest daughter who

not

only obviously remembered her mother with great admiration and deep affection, but had also worked closely with her and, to a great extent, shared her views. It was printed only for private circulation, not published for general retail, so Hope was writing for a specific, select audience of family and friends who, obviously, woUd already have known of her mother's work and wotJd have expected a positive picture of her. They would also have been aware of her formidable and domineering character, but whilst Hope does not try to di~se these traits, she presents them as strengths. Had recollections of their encounters with E.M. (as Hope always refers to her mother) been recorded by some of the many people with whom she clashed, they woUd no doubt

have presented a very different version of events.

Hope incorporated into the biography extensive quotes from autobiographical notes which Elizabeth's ctildren had urged her to write for them in 1889, so it does give some insights into 8izabeth's own thoughts, and these can be ~mented by the views she expressed in her annual DNA reports, which were amongst papers sjven to the GAO by her great-gl'8l'lddalqlter in the 1960s. The papers of her close ~worker,

Lady Lucy Hicks-Beach, COlJ'1tess St Aldwyn, proved more c1ifficUt to locate. The

GAO holds many of the family's estate records and the political papers of her husband, Sir Michael, Earl St Aldwyn, but nothing concerning Lady Lucy's long and devoted involvement with astrict nursing at local, county and national levels. However, a tentative letter of inquiry to the current Lord St Aldwyn of Williamstrip Park near Cirencester was answered with a three-inch thick parcel containing photocq)ies of all Lady Lucy's private papers that are held in the family archives. These papers, which, as far as I am aware, have not been previously used by any other historian, were an invaluable source both of factual information and of the character of the altnistic, compassionate woman they reveal.

(21)

a one-sided view, that of the class which administered the system of rural district nursing, not the nurses who actually delivered the care nor the poor patients who received it. Such documents, particularly DNA Annual Reports, were written with a dual purpose: on the

one

hand, the lady administrator had to present

an

accurate record for the Queen's Council of QVJI; but, on the other hand, she needed to phrase her official statement of facts in such a way that local subscribers would be inspired to continue their support of the work. Surviving Minutes Books also tend to record decisions made, without detailing the reasons and discussions which led to those decisions. Elizabeth Malleson herself tells us that each record "does

not

dwell upon the details of the work. It only sums up a few bare facts." (45) Nevertheless,

as

Hallett says, "even if such works can give us only a few simple facts they may still offer numerous insights". (46)

Within such surviving primary sources, the voices of the nurses themselves

are

heard even more rarely and faintly than the administrators. Even the sigrificance

of

Rorence

Nightingale's involvement in district ... rsing is

not

recognised by Vicinus &

Nergaard. They state that, in their edited collection, "we have included letters representative of the full range of Nightingale's interests". (47) However, whilst they mention that "fU'lds were used ... to

help

lJ1derwrite •.. dstrict ... rsing .. (48), which, by the 1890s, "with its focus upon prevention and sanitation, had become one of

Nidltingale's prime interests" (49), they fail to quote from any of her voluminous correspondence concerning William Rathbone's district Busing scheme in Uverpool, the formation of the Metropolitan Nursing Association,

or

QVJI. The only letter

to

William

Rathbone

that they include is dated

1864

and relates

to

his idea of introducing trained nurses into the Uverpool Workhouse Infirmary.

Contemporary rursing journals, in particular the Nursing Record, first ptbIished in 1888, and the Queen's Nurses' Magazine, fOlJ1ded in 1904, are invaluable sources for the political and professional arguments put forward by leacing ... rses, but where the views

and

records of individual clstrict ... rses are concerned, as MeGam says,

It is better

to

approach archives as

thotQ"1

they were an endangered species, LIlder constant threat, and their survival a cause for celebration.

(22)

There is probably a 50-50 chance in this country of archives being kept and cared for, and when it comes to nursing records, the odds are probably less. (50)

This was the problem faced by Dixon, who catalogued the aVJI archive which was transferred to the Contemporary Medical Archives Centre (CMAC) at the Wellcome Ubrary between 1991 and 1998. Dixon describes how the archivist who lJ'1dertook the initial survey of the records at aVJI headquarters "had to hunt high and low through the building, delving into cupboards, filing cabinets and drawers to locate material which

had been kept for many years ... under conditions which were far from optimum from the point of view of the long term good of the records". (51) Furthermore, a report on the administration of the Institute in 1946 had recommended that "'all obsolete or unnecessary papers, books, etc, be consigned to salvage'" and a further report in 1961 announced with satisfaction the "'regular spring cleaning of the records and dispos[a1] of what is never likely to be of further value'". (52) Consequently, little correspondence survives from before 1946, the eartiest surviving examination paper for Queen's Nurses is from 1924 and the only lectures are from the 19408. However, there is a JUI

run

of AnruaI Reports from 1899, apart from a few gaps from 1901-8, and most

importantly for the purposes of this study, 56 volumes of the Queen's Roll from 1891 to 1937. These record the personal and career details of each Queen's Nurse, including date of birth, marital status, religious denomination, education, father's occupation, own previous occupation, hospital training and nursing experience, district training,

certificates and badges, and J8POI1s on posts held. Each nurse's name was entered on the Roll when she qualified as a Queen's Nurse, and to locate entries for specific nurses, it is necessary to check the 14 volume alphabetical index, listing approximately 35,000 names from 1891 to 1969, and held on microfilm. Whilst it is

straV1tforward

to check for nurses whose forenames are known, where a surname is the only detail already held, it woUd be necessary to call up the Roll entries for every woman listed in the index with that same surname in order to locate the particUar one who worked in Gloucesterstire. Unfortu1ately, in a list of 52 Queen's Nurses who worked in rural districts in Gloucesterstire between 1892 and 1925, whose names it

was

possible to

(23)

collate from surviving local records, 38 have only a surname given, 9 mention initials, but only 5

are

referred to by both a surname and forename. Due

to

problems with my health and with travelling, the laborious task of checking the index and Roll was carried

out

with great enthusiasm and efficiency by Hazel Parris, who managed to find and copy the records of ZT of the Queen's Nurses who worked in Gloucesterstire. Whilst this is a small sample, it is still representative and indicates significant changes in their

social backgroulds during the period covered by ttis study,

as

discussed in Chapter 4. It would be a valuable exercise if a major study of the entire Queen's Roll

was

lJ'ldertaken, collating and detailing these changes nationally over a much wider period,

but such further research is beyond the scope of ttis thesis.

Records of the Village NurselMidwives (VNMs) proved even more elusive. When

the

Gloucestershire Cou1ty Nursing

Association

(CNA) recorded in its Miootes of 1922 that the County Superintendent had moved to a new and bigger office in Gloucester, mention

was

made of the purchase of a fiUng cabinet specifically for storing the

records

and inspection reports of the VNMs. However, none of these documents have survived amongst the records stored at the GRO.

Between

1905 and 1910, some details of applicants were recorded in the CNA Minutes, together with progress reports during training and appointments on qualification. Reference

was

also

made to applicants who were rejected or who failed to complete their training, and these comments can be equally insisjrtflJ and informative. Fewer details were noted between 1911 and 1925, but it proved possible, if painstaking, to trace the careers of some of the longest serving VNMs

tI'votdl

the listings of the

DNAs

and their nurses wtich were included in each of the CNA's AmJaI Reports, and throt.Ol the SUrviving

records of individual

DNAs.

Whilst the dstrict nurses have left little personal evidence of their experiences, as Davin says, "working class memoirs and autobiographies, too, are comparatively few, and by women are rarer still-. (53) Of the few collections that do exist, those most often cited as classic primary sources by

historians

record the lives of the urban working classes: Lady Florence Bell stucied the iron workers' families of

(24)

Middlesbrough, North Yorkshire, for her 1OCJ7 investigation At the WorkS; Maud Pember Reeves questioned 42 families in Kervington and Lambeth in 1913 for Round

About

a

Pound

a

Week; and Margaret Uewelyn Davies edited Maternity: Letters from Working Women in 1915. The perspective of such studies is undoubtec:ly that of the working-class witnesses, but as Davin points

out,

"their evidence was defined by the interests of the investigators, and limited too

no

doubt by class barriers and often the formal context of the enquiry". (54) The questions asked and the way in which they

were phrased could, in itself, have influenced the answers, but the very prejudices and assumptions that such an approach reveals can be historically significant. When Roberts interviewed 160 people, both men and women, born in central and north Lancashire between 1880 and 1914, she foU'ld that there was "very considerable reticence" on

the

subject of sexual behaviour and her respondents were "not lnJSUaI in discussing sex without once mentioning the Word". (55) It is clear from the available

sources that this attitude of prudish disgust and distaste for any topic even remotely COI'I'leCted with reproduction, but particularty for the sexual act itself,

was

widespread amongst the urban working classes throughout the COtJ1try, and was shared by their rural counterparts.

By the nature of their geographical isolation, there

are

even fewer collective memoirs of the rural poor and, in the absence of diverse sources, there is a tendency

for one person's views and experiences to become established as representative of an entire social class and generation. Williams sees Flora Thompson's Lark Rise

to

Cardeford as one such 'rreplaceable record" (56), which, as English says, "has come

to be

used

in ErVand as a text in historical courses as well as in literary classes ... as

a

primary source" from which historians quote "without comment, as if it were of sufficient authority to establish the point being made". (57) However, whilst English concludes that Thompson's chikIlood memories of Oxfordshire in the

1880s

are

"blurred, softened by the art of the writer" (58), the beliefs and attitudes of the rural poor that she

records

are

verified by Rose, who was born in a Buckir9lamshire village in 1871 and recorded his recollections in Good Nei(ftbours (1942); by Chambertain's

(25)

interviews in 1975 with Fenwomen born in Cambridgeshire in the 1890s; by Foley's childhood in Gioucestershire from 1914, recalled in A Clild in the Forest (1974); and by the post-WorkJ War 1 experiences in Suffolk as detailed in Wham Beards Wag All

(1970) by Evans, who Williams describes as "one of the best recorders" of country life in the twentieth century. (59)

Several of Davies' urban respondents expressed resentment of the

atmosphere of sexual ignorance and disgust in which they were raised, and stated their determination not to allow their own daughters to suffer in the same way. (60)

However,

so

deeply ingrained and enduring were the most prudish and repressive moral prejudices of the rural poor that they survived into my parents' generation, born in the 19205, where ttis study ends. I clearly remember my mother, who was raised in a village in rural Essex, having screaming hysterics when, as a teenager in the 1960s, I

dared

to buy my first pair of denim jeans. In a doorn-ladened tone of patronising disapproval, my mother informed me that by "ftalJ'lting" myself in

a

pair of "men's trousers with a zip in the front" , I

was

"asking for trouble!". She insisted that I

wore

a

petticoat lJ1der the jeans, wrapped fOlI'ld my legs and tucked up rOU'ld my crotch, like a cross between a nappy and a chastity belt. Needess to say, I took the petticoat off

at

the first opportuity after leaving the house. In our family, sLbjects such as personal

hygiene, menstruation, sex and pregnancy could never even be mentioned, let alone

discussed, even when I had trained as a nurse, and "locking the bedroom door" was the only acceptable form of birth control for a respectable married woman, as

mechanical methods condoned and encouraged behaviour in men that

was

best

kept firmly lJ'ldar control.

This repressed mentality of the rural poor must have affected the atmosphere in which the lady admiristrators introduced the system of professional

care

and the district oorses carried out their duties, partiaJarly midwifery and family welfare work.

An

lI1derstancing of these

attitudes

and beliefs is,

therefore, essential

if the past is not

only to be recreated but also analysed and interpreted in such a way that, as T osh says, we "find out why people acted as they cid, by stepping into their shoes, by seeing

(26)

the world through their eyes and as far as possible judging it by their standards". (61) Historians confront challenges that other researchers, who produce and control their own data, do

not

face: they have to work, as Rafferty says, "within the compass of [only those] evidential resources and primary sources of data" that have been

preserved by posterity. (62) Even those records which have survived are not, as losh adds, "an open book, offering instant answers .... There is probably

no

other field [of research] whose primary sources are so varied, so widely cispersed, and

so

lntven in quality." (63) However, if we allow "the voice of orcinary people to be heard alongside

the carehJ marshalling of social facts in the written records" (64), we can give history a human face. In particular, as Chamberlain emphasises, "the women's story must be told, but it must be seen in a perspective of its

own ....

Women [need] a sense of their

own

importance and relevance." (65)

To this end, the development of rural district nursing is explored in this Thesis within the broader context of research concerning midch-and upper-class women's role in philanthropy in the period 1880-1925. Firstly, in Chapter 1, the limited range of

health care already available to the rural poor in the

1880s

is established by examining institutional

care

in hospitals and workhouses; the

use

of folk and patent medicines;

and

the Iong-established role of Lady BoootifU. The arrival of Elizabeth Malleson in

rural Gloucestershire coincided with a growing recognition of the need for trained nurses for the rural poor, but this awareness

was

restricted to an enlightened minority amongst the tradtionaIist COU'lty gentry. Elizabeth's long, hard campaig1 to establish a national system of rural cistrict oorsing is described and ciscussed in Chapter 2, which traces the chronology of events from the fou'lding of the RNA to its amalgamation with aVJI. Once Elizabeth, with the help of Lady lucy Hicks-Beach, had

won

the support of the Iandowring classes, the Lades Ba.ntifuI themselves benefitted from the

opporbJ'ities that such ptilanthropic work offered them. What motivated such lades to become involved in the administration of DNAs is considered in Chapter 3, together with what they and the Ieacing figures of aVJI aimed to actieve. Theory is then compared with reality in Chapter 4 by considering the professional status of the district

(27)

nurses, compared with other occupations for women. Their social backgrounds are examined, together with their training and their standing wittin the commlJ'lities they served. The following two chapters describe in detail the working lives of the nurses, their duties, workload, salaries and accommodation. Finally, whether the service they provided was what the poor actually wanted and needed is then examined from the patients' viewpoint in Chapter 7.

Thus, in ttis Thesis, I have attempted to present an integrated portrait of three tiers of rural society, mainly from the women's point of view. To a great extent, the Thesis 'wrote itself, in the

sense

that the primary sources dictated the shape and form

of the study, enabling me to trace not only the chronology and details of events, but also the aims and motivation that inspired the lady administrators and nurses.

However, whilst the local records contained copious factual details, I had hoped to find some records of what the nurses themselves thought and felt about the working and living

cordtions

in which they

were

expected to Mfil those shared aims, rather than having to infer their views from records written by inspectors, committees and administrators. Even those 'grass-root' views that were pti)lished by the Queen's

Nurses'Magazine were filtered through Superintendents' speeches

at

conferences, or selected and ded for publication in the official journal. In adcition, I woUd have Hked to visit the CMAC to study the Queen's Roll, which remains a rich but largely lI1tapped

source. Local oral history woUd also have enriched the study from the patients'

viewpoint, but a request in

a

local history newsletter prompted only

one

response, from

an

articulate and intelligent 91 year old, Mary Paget, who willingly shared her remarkably clear and detailed memories of Charlton Kings in the inter-war years. Nevertheless, despite these obvious shortcomings, it is hoped that ttis study, by combining the quantitative data from surviving local and national records with the qualitative interpretation of the human interaction between the lady administrators, the clstrict nurses

and

their poor patients, win provide a valuable ad«ition to a neglected area of the history of rursing in particUar, and social and women's history in general.

(28)

References (1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36)

Christopher Maggs, 'A New History of Nursing: Changing Perspectives' in

Nursing limes, Va. 80 No. 38 (Sept 19-25, 1984),28-31 (p.31)

Robert Dingwall, Anne Marie Rafferty & Charles Webster, An Introcttction to

the Social History of Nursing (London: Routledge, 1988), p.173

Erid Nora Fox, District Nursing & the Work of District Nursing Associations

in England & Wales, 1~ (Ul'lpli)Iished PhD Thesis, London University, 1993), pp. 14, 36 & 24

Dingwall et ai, Social History of Nursing, p.173

Mary Stocks, A HlIJdred Years of District Nursing (London: Allen & Unwin, 1960), p.81

Monica E. BaIy, A History of the Queen's Institute (Beckenham: Croom

Helm, 1987), p.59

Christopher Maggs, The Ori{ins of General Nursing (Beckenham: Croom Helm, 1983), p.3

Celia Davies, 'The Contemporary Challenge in Nursing History' in Rewriting Nursing History, ed. by Celia Davies {London: Croom Helm, 1980), pp.11-17 (p.14)

Brian Abel-Smith, A History of the Nursing Profession (london: Heinemann, 1960), p.xi

Maggs, Ori(jns, p.3 Ibid, p.2

Malcolm S. Newby, 'Problems of Teacting Nursing History' in Nursing TImes, Va. 75 No. 30 (Nov 22-28, 1979), 123-124 (p.123)

Barbara

Mortimer, 'Cou1ting Nurses: Nursing in the Nineteenth Century Census' in Nurse Researcher, Va. 5 No. 2 (Winter 1997198), 31-43 (p.42)

Ross McKibbin, The Ideologies of Class (Oxford University Press, 1991), p.177

Gareth Stedman Jones, Outcast London (Oxford: Clarendon, 1971), pp.250-261

F.K. Prochaska, Women & F'tiIanthropy

in

Nineteenth Century England

(Oxford Uriversity Press, 1980), pp.135 & 137

Arne Summers, 'A Home from Home: Women's Philanthropic Work in the

Nineteenth Century' in Fd Work for Women, ed. by Sandra Burman (london: Croom Helm, 1979),

pp.33-63

(p.38)

Prochaska, Women & Philanthropy, p.125 Summers, 'Home from Home', p.33 Prochaska, Women & Pfilanlhropy, p.124

Lee Holcombe, VICtorian Lades at Work (Newton Abbot: David & Charles, 1973), p.68

Ibid, p.89

Dingwal et ai, Social History of Nursing, p.178 Summers, 'Home from Home', p.42

Prochaska, Women & Philanthropy, pp.114-6 Holcombe, VICtorian Ladies,

p.92

Prochaska, Women & F'tiIanthropy, p.135

G.E. Mingay, Rural Ute

in

VICtorian England (Stroud: Sutton, 1976), pp.20-1 Ibid, p.188

Ibid, p.28 Ibid, p.166 Ibid, p.45

Jessica Gerard, 'Lady Bou1tifU: Women of the landed Classes & Rural Ptilanthropy'in VICtorian

Studes,

30 (Winter 1987), 183-210 (p.183) Pamela Hom, LacIes of the Manor: Wives & Dsu{lJters

in

Cocntry-house

Society 1B.»1918 (Stroud: Sutton, 1991), p.3

Ibid, p.S Ibid, p.11

(29)

(37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65)

Gerard, 'Lady Bountiful', p.186 Ibid, p.205

Ibid, p.192 Ibid, p.206 Ibid, p.202

A. Susan Williams, Ladies of Influence: Women of the Elite in Interwar Britain (London: Penguin, 2001), p.12

Ibid, p.180

Gerald Bowman, The Lamp & the Book:The Story of the ReN, 1916-1966 (London: Queen Arne Press, 1967), p.30

GRO

04057/15

Gotherington DNA

AmuaI

Reports

1 mn.1916

Christine Hallett, 'Historical Texts: Factors Affecting their Interpretation' in Nurse Researcher, Vol. 5 No.2 (Winter 1997198), 61-71 (p.70)

Martha Vicinus & Sea Nergaard (eds.), Ever Yours, Florence Ni(frtingaJe: Selected Letters (London: Virago, 1989), p.1

Ibid, p.5 Ibid, p.424

Susan McGann, 'Archival Sources for Research into the History of Nursing' in Nurse Rsearcher, Vol. 5 No. 2 (Winter 1997198),19-29 (p.19)

Shirley

Dixon,

'The Archive of the Queen's Nursing

Institute

in the Contemporary Medcal Archives Centre' in AfedcaJ History, April 2000, 251-266 (pp.251-2)

Ibid, p.253

Anna Davin, Introduction

to

Margaret Llewelyn Davies (ed.), ute As We Have Known It by Co-operaJive Worlcing Women (London: Virago, 1977

ecition;

first ptj)Iished 1931), pp.vii-ix (p.vii)

Ibid

8izabeth Roberts, A Woman's Place: An Oral History of WorIciIw-CIass Women 1890-1940 (Oxford: Blackwell, 1984), p.75

Raymond Williams, The Cantry & the City (London: Hogarth, 1993 edition; first ptbIished 1973), p.261

Barbara English, 'Lark Rise & Jlriper Hill: A Victorian CommlJ'lity in

Uterature & History' in VICtorian StucIes, Vol. 29 No. 1 (Autumn 1985), 7-34 (pp.7 & 14)

Ibid, p.34

Winiams, CocIrtry & City, p.261

For examples of these views, see Margaret Llewelyn Davies (ed.), Materrity. Letters from Working Women collected by The Women's Co-operaJive GtJId (london: Virago, 1978 edition; first published 1915), pp.44, 62, 78 & 80

John Tosh, The

PursUt

of History (london: longman, 1991), p.14

Am Marie Rafferty, Writing, Researching & Reftexivity in Nursing History' in Nurse Researcher, Vol. 5 No.2 (Winter 1997198), 5-16 (p.6)

Tosh, PursUt of History, pp.55 & 100 Ibid, p.210

Mary Chamberlain, Fenwomen: A Portrait of Women in an English Village (london: Virago, 1975), pp.12-13

(30)

Gotherington in the late 19th century

Source: David Aldred, Gotherington Local History Society

(31)

Introduction

CHAPTER ONE

HEALTH CARE IN THE 188Qs

Before examining the introduction of district nursing, it will be valuable to establish the limited range of health care that was already available to poor rural

communities in the 1880s. To this end, firstly this chapter will consider institutional

care

in hospitals, cottage hospitals and workhouses. National movements and policies

will be related to specific experiences in Gloucestershire by the examination of local institutional records. The role of pharamacists will then be examined, together with the use of folk remedies and patent medicines. Finally, the role of lady Bountiful will be discussed in the context of the cUturai philosophy of domesticity and philanthropy.

Institutional

care

In 1873, Florence Nightingale asked the rhetorical question:

To reform the Nursing of all the Hospitals and Workhouse Infirmaries in the world, and to establish District Nursing among the sick poor at home, too ... - is this

not

an object most worthy of the co-operation of all civilised people? She fou1d it gratifying that, "in the last ten years, thank God, numerous Training Schools for Nurses have grown up, resolved to unite in putting a stop to such

a

thing as dlU1ken, immoral, and inefficient Nursing" and she believed that, "within a few years

... [It] will be a disgrace to any Hospital or even Workhouse to be suspected of bad Nursing or to any district ... not to have a good District Nurse to nurse the sick poor at

home". (1) However, thousjl the Nightingale reforms had begul to take effect

on

hospital nursing by the 1880s, Summers points out that

for much of the rineteenth century neither minor nor major illness was automatically thotJsj1t to require institutional treatment. The rich, and indeed any patients with pretensials to gentility, were nursed at home; the poor dd everytting in their power to avoid entering the workhouse infirmary or sick ward. The vollJ'1tary hospitals catered for a small section of the sick poptjation

... but, over most of Britain, most sickness

was

treated at home. (2)

Aorence Nightingale envisaged home nursing, as Dingwall et aI express it, as "a civilizing occupation, reforming and redirecting the lives of its patients,

not

just caring for them". As well as providng the sick poor with the same standard of nursing as the

(32)

middle-and upper-classes, home nursing was a means of teaching domestic hygiene and basic sanitary principles, "a way to separate the [sick] poor from each other rather than grouping them together in hospitals". (3)

Standards in hospitals still varied in the 1880s, as there was no uniform training

nor

a national register. Individual hospitals still issued their own certificates, either to working-class girls who trained for two to four years, depending on the hospital, or to 'lady' pupils who paid £1 a week each for a year's tuition, at a time when the average weekly wage for a male agricultural labourer was only 13s.9d. Demographic changes had reded in

an

ever-increasing number of such ladies from the midde- and upper-classes who needed to work. The census of 1881 recorded

more

than 13 million women in England and Wales, compared with 12.5 million men. By 1901, these figures were almost 17 million women and fewer than 16 million men. In the overall population in 1881, there were 1,055 women to every 1,000 men; by 1901, the ratio was 1,068 per 1,000. In the economically productive age group of 20-44, the

ratio

was

1,083 per 1,000 in 1881, rising to 1,096 per 1,000 in 1001. These 'superfluous' women needed

to

find work which, in Maggs' words, "would support them not for a few years lI'1til marriage but for their entire life". (4) These figures apply to the population as a whole, but Holcombe points

out

that ttis disproportion between the sexes was greater among the mic:kte classes than the working classes, due to "the excessive emigration of men of their class, who were responding to the calls of far-fllJ'lg empire and seeking new lives in new

worlds",

as a red of which they either postponed or abstained from marriage. (5)

Demographic changes therefore coincided with the reform of nursing, creating a pool of

potential

labour of precisely the calibre which

Florence

Nvmngale aimed to

attract.

Holcombe points

out

that "nursing was always considered to be women's work ... so mid-Victorian feminists cid not have to make

out

a case for the suitability and desirability of women's employment. Rather, ... [they] faced the problem .•. of raising [nurses] to the status of

true

professionals." (6) Bingham adds that "raising the standing of nurses ... woUd raise the standing of women - an ambition in tlr1e with

(33)

23 the femirist mood of the age. As Mrs Bedford Fenwick, 'commanding officer' in the batHe for registration, said, 'The Nurse question is the Woman question, pure and simple.'"

m

Aorence Nightingale believed that the recruitment of middle- and upper-class 'lady probationers' woUd transform nursing into a respectable occupation

because, as BaIy expresses it, "the notion of paying for a training carried intrinsic merit and kudos .... It was more than the kudos of the ability to pay, it was the concept that entering the profession was

so

worthwhile that it was worth [paying] .... This was publicity in itself," wtich in

tum

would then

attract

more recruits from those classes. (8)

The medical profession was slow to agree, as the

Lancet

declared with chauvinistic conviction in 1879:

We cannot unreservedy subscribe to the popular belief that nursing ... is an

occ~ which is at all suited to ladies who have been delicately brought LIP, and we feel sure that the lady who is ready to perform all those disagreeable duties which are necessary (let us say) for the prevention of bedsores must be a rarity .... Such work is, we feel sure, better entrusted to strong, properly

trained women of the lower class who have been accustomed to dirty work

from their youth up, and who are never squeamish over their duties. (9) The following year, the British MedcaJ Journal expressed the patronising belief that:

Ladies, as a rule, do not make first-rate nurses .... l..a<ies take to nursing, as a rule, from sligrtIy morbid motives; they are 'disappointed', or they want

something with which to kill emi, or they have religious convictions on the subject. (10)

Miss Nightingale herself was acutely aware of the dangers of such a popUar image, both from the disparaging point of view of men and from the appeaJ it might hold for idealistic and naive yot.rlQ women. She did expect a nurse to be "a religious and devoted woman ... [with] a respect for her

own

calling" (11), but she envisaged efficient, well-trained professionals,

not

martyrs. "It seems a commonly received idea among men and even among women themselves that it requires nothing but a disappointment in love ... to tum a woman into a good nurse," she wrote (12), but

A woman who takes a sentimental view of Nursing (which she calls 'ministering', as if she were an angel), is of course worse

than

useless. A woman possessed with the idea that she is making a sacrifice will never do· and a woman who ttinks any kind of Nursing work 'beneath a Nurse' will '

simply be in the way .... Nurses' work means downright work, in a cheery, happy, hopefU, friencIy spirit.

An

earnest, brVlt, cheerful woman, without that notion of 'making sacrifices', etc, perpetuaRy occurring to her mind, is the real

(34)

Nurse, ... that is the woman we want. (13)

This ideal Nightingale nurse would bring to her work "a strong practical, intellectual interest in the case" (14) and an attitude of "intelligent obedience to rules and

orders". (15) As Stocks says, Florence Nightingale sought to establish nursing not "as a craft for the lower orders", but "as a profession for educated women". (16)

Again, the

Lancet

was quick to disagree, insisting unequivocally that "the nurse

cxVrt

to be the servant of the doctor" and railing dsmissively at any suggestion that nursing could even be called a 'craft' let alone a 'profession':

Nursing is

not

a craft; still less can it be regarded as a profession .... A trained nurse is a half-educated woman, who has acquired just enough

knowledge to make her dangerous ... [and] by entrusting the duty [of care] to trained nurses they [doctors] are jeopardising the lives or the health of the patients. (17)

This view was still entrenched in the pre-Nightingale era, when even the taking of temperatures and pulses and the testing of urine was the work of the medical

students, and it smacks of professional jealousy as much as of male chauvinism. The

Lancet

might metaphorically stamp its foot and stubbornly refuse to accept the need for trained, educated nurses, but that need

was

an integral part of medical progress. It both arose from and reflected what White describes as a "shift in the philosophy and goals of medcal treatment from alleviation of suffering to cure", (18) which itself

derived from contemporary scientific dscoveries. Chloroform became the most widely

used anaesthetic, in preference to ether, after it was first introduced in medical practice by Sir James Simpson in 1847, and as White points out, "as operations became more extensive, so the post-operative nursing needs of the patient became more complex and demancing". (19) From the 1860s, the application of Uster's antiseptic principles,

based on Pasteur's germ theory of cisease,

not

only reduced surgical mortality rates from between

25-4096

in 1865

to

approximately 4% in 1890, but also further developed nurses' technical skills in aseptic tectviques and more and improved dressings. Germ theory and the control of infection developed further in 1876 when Robert Koch

identified the fu1ction of bacteria in the cJsease process. As a red of such scientific and medical advances in the latter half of the nineteenth century, Wtite tells us, doctors

(35)

had increasi~

to rely on the skilled observation and discretion of the ruses who were in constant attendance on the patients (in contrast

to

the doctors' intermittent visits) .... As greater specialisation in medcine and surgery developed, SO

<id greater specialisation in rursing grow. (20)

25

These improvements were reflected in hospital data, both nationally and locally. At Cheltenham Hospital in 1880, a total of 629 'in-door' patients were admitted, ·409 of whom were cischarged cured, and 161 relieved". The average runber of patients in

the hospital at any one time was 63.86 and the average time each patient remained on

a ward was

38.07

days. The

99

surgical operations performed that year included

19

amputations, from wtich two patients died of shock. Amongst the mecical patients,

the most commony treated cordtions were 32 cases of rheumatism, of which 28 were cured and 4 relieved; 18 cases of anaemia, all cured; 13 skin ucers, 12 cured, 1

lJ'lrelieved; 13 cases of pneumoria, 10 cured, 1 relieved, 2 died; 8 cases of bronchitis, all cured; and 8 cases of heart cisease, 4 cured, 4 died. Overall, "the deaths in the

Hospital have been greater in runber this year than usual, amotJ'1ting in all

to

37, 14 of

wtich were the reds of accidents-. (21) When these 14 fatal accidents are

ciSCOU'lted, the death rate amongst patients in 1880 falls from 5.88%

to

3.66%, wtich

compares favourably with 3.94" in 1879 and 3.1" in 1878.

Y at, despite such reds, AbeI-8mith tels us, the more prosperous classes still -entered the hospitals only

to

visit, inspect or govem-; they remained

institutions

wtich cared primarily for the poor, amongst whom the fear persisted that -admission

to

hospital was the precursor of death-. (22)

In mq rural areas, there were no hospitals 8'ld it was

to

combat this problem

that Cottage Hospitals

were

established, the first being fa.nted in 1859 by Mr Albert Napper MRCS at CrsnIe9l

n Surrey.

As the name suggests, the earliest of these hospitals were set ~ in converted cottages where a resident ruse provided care for four

to

ten patients and a general practitioner paid regUar visits. Over the

years, many

such hospitals

were

extended or moved

to

new,

purpose-btjIt premises, -resUting from the absolute necessity of providng better accommodation for the poor in cases of sickness

or

accidn than that afforded

n

their own homes-. (23)

(36)

Bourton-on-the-Water Cottage Hospital

was

only the third such hospital to be

established in Ergand, when Dr John Moore leased Buryfield Cottage in 1861. A new building was erected on a cifferent site in 1879, and was in tum succeeded by a new hospital in 1928. (24)

Miss Rebecca Home, the first Matron of Moreton-in-Marsh Cottage Hospital has left her recollections of its fOlJ'ldation in the 1870s when "Dr Leonard Yelf was attending my friend Miss Challis, in my home, during

a

long illness and being (I

s~) pleased with my nursing, he said how much he wished he could get a bed in some cottage, which he could use for some poor patient." He approached a local patron, Lord Redesdale, who generously offered a site for a small hospital and £150 towards the bUlding

costs.

Whilst the hospital was lJ'1der construction, Miss Home joined

a

group of nurses at Winchester, who were being trained there by the Nightingale FlJ1d, which illustrates that, aIttlolql the hospital was envisaged primarily as provking respite

care,

the nursing

was

expected to be of

a

hVl

standard. The new hospital

was

opened by the Bishop of Gloucester on 24 July 1873 and the first

two

patients were admitted four days later. Miss Home recalls, "20 others followed before the end of the year and only

one

of those was 'ulcer of leg' thus cisproving the prophecy of

a

friend (who afterwards became

an

energetic helper in the Hospital) who said

we

should never get any patients except old women with bad legs!" (25)

The willingness of

a

local patron to fu1d

a

new purpose-bUll hospital, instead of merely converting

a

cottage, reflects the growing

awareness

of the need to make

provision for rural patients who could not afford private nursing at home, but whose

concition was not serious

er1OUlt1

to wanant removal to an urban hospital. The criteria for admission were clearly set

out

in the Rules of Fairford Cottage Hospital, founded in 181J7, which state that, "The Hospital is designed for the benefit and accommodation of

the poor when suffering from Disease or Accident; but no case of Infectious or

Contagious Disease, or of Pulmonary Consumption, shall be admissable." All costs

and

expenses

were

met

by charitable donations and Sli>scriptions, but patients

were

References

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